Restraints and seclusion in psychiatry: striking a balance between protection and coercion. Critical overview of international regulations and rulings.

Restraint and seclusion (R&S) measures in psychiatric settings are applied worldwide, despite poor scientific evidence to back up their effectiveness. The medical, ethical and medico-legal implications of coercive interventions are broad-ranging and multifaceted. The review aims to shed a light on the most relevant and meaningful standards that have been laid out by international treaties, supranational institutions (United Nations, Council of Europe, World Health Organization), scientific institutions (American Medical Association, Australian Department of Health), legislative bodies and courts of law. Several court cases are herein expounded upon, with a close focus on meaningful analysis, decisions and conclusions that have laid the groundwork for a different, more restrictive and more clearly defined approach towards R&S imposed upon psychiatric patients. It is reasonable to assume that changing norms, civil rights enforcement, court rulings and new therapeutic options have influenced the use of R&S to such an extent that such measures are among the most strictly regulated in psychiatric practice; health care providers should abide by a strict set of cautionary rules when making the decision to resort to R&S, which must never be put in place as a substitute for patient-centered therapeutic planning. Case law shows that R&S should only be weighed in terms of their effectiveness towards therapeutic goals. Being able to prove that R&S was employed as part of a therapeutic path rather than used to maintain order or to exact punishment may go a long way towards shielding operators against negligence lawsuits and litigation.

Exercise of human rights of institutionalized persons: perception of psychiatric hospital professionals.

OBJECTIVE: to comprehend the existing possibilities for the exercise of human rights by persons with mental disorders who are institutionalized in a psychiatric hospital, from the perception of professionals. METHOD: this is a qualitative descriptive-exploratory study conducted at a Psychiatric Hospital in the state of São Paulo, Brazil. For data obtention, eleven professionals responded to a semistructured questionnaire. The traditional content analysis proposed by Bardin based the data analysis. RESULTS: the professionals know the human rights and try to preserve them in the hospital scope, although they recognize that the persons hospitalized are not entirely respected due to the lack of public policies or their non-suitability to the Brazilian reality. FINAL CONSIDERATIONS: the structuring of extra-hospital services is necessary, as well as the comprehension of the professionals that act in psychiatric hospitals about the objectives and the functioning of such devices to assure opportunities of exercising rights by institutionalized persons.

[The non-meaningfulness of psycho-behavioural disorders with dementia]. / Le non-sens des troubles psycho-comportementaux de la démence.

Dementia questions and undermines the content exchanged and relational codes. What is the true nature of these disorders? While they are not psychotic disorders, they evoke a psychiatric revelation of Alzheimer's disease. It is therefore necessary to design a mental health policy which is equal for everyone and encourage ethical reflection around the issue of care.

'You can't be forcing food down 'em': Nursing home carers' perceptions of residents' dining needs.

Malnutrition is a life-threatening condition among older people living in nursing care homes. This qualitative analysis of interview data from five care staff aimed to understand their perceptions of 'caring for' residents' nutritional needs. Tensions in the delivery of care and institutionalisation and disempowerment were identified. Despite carers' good intentions, they often failed to recognise the importance of the psychosocial aspects of mealtimes. Staff shortages, routine-driven, medically based working practices and residents' resistance to institutionalisation emerged as barriers to quality caregiving. The findings indicate that the relational aspects of care are constrained by social, structural and ideological contexts.

Rehabilitation, Education, and the Integration of Individuals with Severe Brain Injury into Civil Society: Towards an Expanded Rights Agenda in Response to New Insights from Translational Neuroethics and Neuroscience.

Many minimally conscious patients are segregated in nursing homes, and are without access to rehabilitative technologies that could help them reintegrate into their communities. In this Article, we argue that persons in a minimally conscious state or who have the potential to progress to such a state must be provided rehabilitative services instead of being isolated in custodial care. The right to rehabilitative technologies for the injured brain stems by analogy to the expectation of free public education for children and adolescents, and also by statute under the Americans with Disabilities Act and under Supreme Court jurisprudence, namely the leading deinstitutionalization case, Olmstead v. L.C. ex rel. Zimring.

French lay people's and health professionals' views regarding the acceptability of involuntary treatment of nursing home residents.

OBJECTIVES: We examined the views of lay people and health professionals in France about involuntary treatment of residents in nursing homes. METHOD: Participants (101 lay people, 20 nurses, 20 psychologists, and 10 physicians) were presented with a series of stories created by varying the levels of five factors: type of behavioral problem encountered (e.g., night-wandering), associated signs of dementia, physician's effort to explain the reason for treatment, resident's attitude (e.g., lasting reluctance), and physician's decision to prescribe psychotropic drugs or not. Participants were asked to judge the acceptability of the decision in each concrete case. RESULTS: Three qualitatively different positions were found. The largest group (40% of the participants) viewed treatment of residents' behavioral problems as the most important objective. They felt it also important to respect residents' wishes and, therefore, to spend much time in talking with them about treatment. An almost equally large group (39%)--which included 60% of physicians--viewed respect for residents' autonomy as the most important consideration. A smaller group (21%)--including 40% of the psychologists--focused on the importance of taking time to talk with the residents. They also thought that treating patients against their will was unacceptable. Thus they took autonomy one step further than the preceding group. CONCLUSION: It is important to reduce as much as possible the conflict between the principles of patient autonomy and perceived beneficence when caring for nursing home patients with behavior problems. This can be done by promoting their decision making abilities.

'A disease that makes criminals': encephalitis lethargica (EL) in children, mental deficiency, and the 1927 Mental Deficiency Act.

Encephalitis lethargica (EL) was an epidemic that spread throughout Europe and North America during the 1920s. Although it could affect both children and adults alike, there were a strange series of chronic symptoms that exclusively affected its younger victims: behavioural disorders which could include criminal propensities. In Britain, which had passed the Mental Deficiency Act in 1913, the concept of mental deficiency was well understood when EL appeared. However, EL defied some of the basic precepts of mental deficiency to such an extent that amendments were made to the Mental Deficiency Act in 1927. I examine how clinicians approached the sequelae of EL in children during the 1920s, and how their work and the social problem that these children posed eventually led to changes in the legal definition of mental deficiency. EL serves as an example of how diseases are not only framed by the society they emerge in, but can also help to frame and change existing concepts within that same society.

Ethics support in institutional elderly care: a review of the literature.

Clinical ethics support mechanisms in healthcare are increasing but little is known about the specific developments in elderly care. The aim of this paper is to present a systematic literature review on the characteristics of existing ethics support mechanisms in institutional elderly care. A review was performed in three electronic databases (Pubmed, CINAHL/PsycINFO, Ethxweb). Sixty papers were included in the review. The ethics support mechanisms are classified in four categories: 'institutional bodies' (ethics committee and consultation team); 'frameworks' (analytical tools to assist care professionals); 'educational programmes and moral case deliberation'; and 'written documents and policies'. For each category the goals, methods and ways of organising are described. Ethics support often serves several goals and can be targeted at various levels: case, professional or organisation. Over the past decades a number of changes have taken place in the development of ethics support in elderly care. Considering the goals, ethics support has become more outreaching and proactive, aiming to qualify professionals to integrate ethics in daily care processes. The approaches in clinical ethics support have become more diverse, more focused on everyday ethical issues and better adapted to the concrete learning style of the nursing staff. Ethics support has become less centrally organised and more connected to local contexts and primary process within the organisation.

Translating Fanon in the Italian context: rethinking the ethics of treatment in psychiatry.

Based on two years of ethnographic fieldwork at the Centro Frantz Fanon, an ethnopsychiatric clinic in Northern Italy, this article traces the theoretical and clinical genealogy of Italian ethnopsychiatry as it is conceived and practiced at this clinic. The clinic draws explicitly from the work of Fanon and French ethnopsychologist Tobie Nathan. This genealogy provides a basis for reflection on the ways in which current ethnopsychiatry re-articulates older questions about difference and healing, culture and suffering, and the political dimensions of psychiatry. Although ethnopsychiatry is currently focused on the care of migrants, key issues related to the impact of colonialism on mental illness and the recognition of cultural difference characterized the Italian debate long before the 1980s when increasing numbers of migrants and political refugees started to arrive in Italy.

[Promoting the dignity and respect of elderly people in institutions]. / Promouvoir la dignité et le respect de la personne âgée en institution.

How can caregivers avoid the mechanical nature of the repetitive care given to elderly people in institutions? As part of a training programme set up in the long-term care home of Saint-Pierre-le-Moutier, a group of caregivers considered this question. On the basis of an ethical approach, they created tools to offer a form of dignified care which respects both the resident and the caregiver.

Políticas de saúde pública: interação dos atores sociais / Public health policies: interaction of social actors

O livro analisa a legislação que explicita o modus operandi do SUS, estabelece a operacionalidade dos meios para o atendimento eficaz da parcela mais pobre da população e explicita os critérios que possibilitam uma boa e pessoal interação entre o médico e o doente.

Locked inpatient units in modern mental health care: values and practice issues.

Locked inpatient units are an increasing phenomenon, introduced in response to unforseen abscondences and suicides of patients. This paper identifies some value issues concerning the practice of locked psychiatric inpatient units. Broad strategies, practicalities and ethical matters that must be considered in inpatient mental health services are also explored. The authors draw on the published research and commentary to derive relevant information to provide to patients and staff regarding the aims and rationales of locked units. Further debate is warranted in relation to best practice. Inpatient staff need to be aware of their practice values, be able to access education and supervision and negotiate apparent contradictions. Further patient/clinician focused enquiry is necessary to mitigate the negative and stigmatising effects of locked mental health units.

Aspectos ético-legalesdel internamientoen psiquiatría / Ethical-legal aspects of admission into a psychiatric ward

En la actualidad, el papel de los profesionales sanitarios hapasado de ser meros controladores de los enfermos mentalesa ser cada vez más parte activa en el tratamiento de los mismos.En España, la institucionalización facilitó una culturapaternalista, si bien la reforma psiquiátrica, al integrar la psiquiatríaen la sanidad general y establecer dispositivos asistencialescomunitarios, ha creado un nuevo tipo de relación entrepaciente y profesionales. En la práctica psiquiátrica esnecesario identificar aquellos problemas que puedan suponerun conflicto ético y garantizar el respeto a los derechos fundamentalesde las personas, principios éticos que entran enconflicto en la práctica diaria en temas como el internamientoinvoluntario, sea civil o penal. Los pacientes son seres moralmenteautónomos, con capacidad para tomar sus propiasdecisiones y éstas deben ser respetadas, ya que se le debe facilitarla participación en el proceso de toma de decisiones.Se ha revisado la legislación vigente sobre los tipos de internamientos,así como las implicaciones éticas que comporta (AU)

At present, the role of healthcare professionals has shiftedfrom being mere controllers of mentally ill patients to becomingan increasingly active part of their treatment. In Spain, institutionalizationfacilitated a paternalistic culture. Psychiatricreform, by integrating psychiatry into general healthcareand establishing community healthcare action directives, hascreated a new type of relationship between patient and professional.In psychiatric practice it is necessary to identifyproblems that may entail an ethical dilemma and guarantee thesafeguarding of people’s fundamental rights, ethical principlesthat often class in daily practice in cases of admittanceagainst the will of the patient, be it civil or penal. Patients aremorally autonomous beings, with the capacity to make theirown decisions, and these decisions should be respected, giventhat the patient should be allowed and encouraged to participatein the decision-making process to the greatest extentpossible. Current legislation on types of admissions, as wellas their ethical consequences, has been reviewed (AU)

[Compulsory hospital admission - coercive measures in medical care]. / Die ärztliche Einweisung - eine Zwangsmassnahme in der Medizin.

Any coercive medical intervention is a massive curtailment of the affected person's freedom that is in direct contradiction to their right to self-determination. This is why any such intervention must be laid on a solid legal and ethical foundation. Any decision to commit a person against their will for medical care will have to be made with due regard for both the institution's medical duty and society's interest in public safety. Any such decision must also involve careful consideration of whether the individual concerned is at acute risk of harming or injuring themselves or others as a result of their mental condition. Involuntary committal may be perceived as extremely insulting by the person concerned, who may feel that their right of self-determination has been violated; and at least for a limited period it will inevitably make them feel that they are not being treated like or regarded as an adult. Hence, the following ethical questions arise: Is it justified to suspend an individual's right of self-determination - if only in terms of their place of residence - by committing them for medical treatment and care? And how can such coercive committal be reconciled with the ethical medical principles of autonomy, beneficence, justice and non-maleficence? There are no stock answers or checklist answers to these questions. Whether a committal is warranted must ultimately be decided on a case-by-case basis by thoroughly assessing, weighting and comparing the various principles and considerations involved.

Consideraciones teóricas para el estudio de la dimensión institucional del desarrollo de la ciencia en Cuba / Theoretical considerations for studying institutional dimension of science development in Cuba

El presente artículo tiene como objetivo fundamentar un marco teórico que permita estudiar el proceso de institucionalización de la ciencia en Cuba. Al enfocar la ciencia como actividad, su dinámica e integración dentro del sistema de las actividades sociales; se le debe prestar especial atención al proceso de institucionalización. Se justifica el abordaje de los procesos de institucionalización de la ciencia cubana como procesos específicos condicionados por lo económico, lo político y lo cultural. El trabajo consta de los siguientes momentos: primero se trata de develar el papel que juega la política científico- tecnológica en el desarrollo del proceso institucional; segundo, se caracteriza el lugar de la gestión de la actividad científica, y por último, se utiliza el enfoque de la red de actores para desentrañar los nexos y relaciones que se producen en el proceso de institucionalización(AU)

This paper is aimed at supporting a theoretical framework to study the institutionalization process of science in Cuba. When focusing on science as an activity, on its dynamics and integration within social activities, a special attention must be given to institutionalization. Dealing with the institutionalization process of Cuban science is conditioned by specifically economical, political and cultural factors. This paper firstly exposes the role of the scientific technological policy in the development of the institutionalization process. Later on, the place of scientific activity management is characterized. Finally, the approach of those involved is used to clear up the links and relations produced along the institutionalization process(AU)

Consideraciones en torno a la atención de las personas con demencia en residencias. Controversias entre los principios bioéticos / No disponible

El presente artículo constituye sólo una parte de una amplia revisión bibliográfica que en torno a los aspectos bioéticos de la atención al anciano con demencia en Residencias se realizó para el Master en Psicogeriatría 2004-2006. Para esta publicación se ha seleccionado la controversia existente en torno a la pertinencia de los clásicos principios de bioética: autonomía, beneficencia, no maleficencia y justicia, en su aplicación a la atención a las demencias en instituciones de larga estancia. Se analiza como estos principios se concretan, para la aproximación a esta problemática, así como la consideración más precisa de otros principios, que en el marco considerado cobran particular relevancia (AU)

No disponible

[Decision of institutionalizing an elderly parent suffering from cognitive impairments]. / L'hébergement institutionnel d'un parent âgé ayant des pertes cognitives

This study examines the decision of institutionalizing an elderly parent suffering from cognitive impairments and the various people involved in this process: the elderly person, the informal caregiver, certain family members and health and social service professionals. Based on a qualitative analysis of interviews conducted with 16 elderly people and their family networks, this study reveals the importance of considering the point of view of everyone involved. The results show that one of the main reasons behind the decision to institutionalize an elderly person is the appearance of disturbing behaviours related to his or her cognitive impairments. Diverse strategies used by family members and health and social service professionals in order to bring about the institutionalization of an elderly person when he or she is opposed to it are presented as well as the ethical dilemmas this raises. We conclude with a presentation of research and intervention recommendations.